08-01-2025
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
PPM 1 - Reviewing this failed PaJR patient who lost informational continuity so much so that when I met her today, I thought she was a new patient!
Caretaker - The below are the tablets taken by the patient. 👇
PPM 1 - The above tablet 👆 Flunarin 10mg only once, one hour before dinner.
PPM 1 - The above 👆 tablet is only when she develops giddiness.
PA - Now she is having giddiness. She has taken the Phenergan 25 at 1.30pm. After how long should she take that tablet again? She took flunarin also in the afternoon, so I asked them not to give again in the night before dinner. She is also having headache now. The caretaker is asking whether he can come at any time to the hospital if medical emergency arises.
PPM 1 - 👍
PA - Please don't give any tablets for today. Her dosage is complete.
PPM 1 - Phenargan is 8 hourly
She can take Paracetamol 1gm for her headache 6 hourly
Yes our emergency is open 24x7
Paracetamol 1g 6 hourly as her body weight is higher.
09-01-2025
Caretaker - BP is 180, not in control. Please advise.
PPM 1 - Check every hourly and inform both systolic and diastolic
Share a picture of the BP recorded.
PA - Doctor the patient's BP is not under control. They are coming to the hospital
PPM 1 -
Fine.
We shall admit and share the BP charting here
I guess this is a side effect of the new machine they purchased yesterday and perhaps a side effect of PaJR micromanagement! @PPM2.
PPM 2 - Yes.
Caretaker - The patient is experiencing giddiness. Should we give the above tablet?
Caretaker - Sir is this 👇tablet for BP?
PPM 1 - What happened?
Did he go to another doctor and inspite of being connected we appear to have been unable to help him!
It seems he got a chaotic morass of prescription to feed his fearful BP frenzy, which surprisingly got activated since yesterday while the group lay idle since July 2024!
Something in yesterday's OPD interaction appears to have tipped the balance @PPM3?
PPM 3 - No sir this is @PPM4 sirs handwriting.
@Caretaker Please post picture of yesterday's prescription.
PPM 1 - OMG! He should have been added to this group earlier!
Why is the patient's advocate not sharing any BP reading hourly and simply panicking from pillar to post?
PPM 3 - Yesterday we counselled to buy one digital monitor and share with us.
@Caretaker, yesterday we asked you to buy a digital BP monitor. Did you buy?
Caretaker - Yes, today we bought.
PPM 3 - Please share the patient's BP readings here. We will let you know the proper medication.
Caretaker - Okay madam.
Caretaker - BP reading at 5.36pm is 161/110.
PPM 1 - Please share what BP medicines the patient was taking before this.
Caretaker - In the morning the doctor had given 10mg BP tablet.
After coming back from hospital at 5.37pm, checked the BP.
The patient is complaining of headache.
PPM 3 - We have prescribed him other medications for migraine. He got some other medications.
Now shall i ask the patient to take Telma 40mg sir? @PPM1 sir.
@Caretaker yesterday we have prescribed medicines for the patient. Didn't you get them?
For headache, giddiness, and thyroid.
Caretaker - The patient did not take Flunarin 10mg.
PA - The patient is having headache and want a painkiller.
PPM 3 - I talked to the caretaker.
Patient already took PCM
Yesterday we advised to use flunarizine for migraine
Headache could be because of hypertension or migraine so I am waiting for @PPM1 sir reply if we can start on anti hypertensive.
Now patient has one sided headache which should get better with PCM.
PPM 3 - This is today's prescription. Yesterday we have given you another one. Where is that?
Did the patient take BP tablet in the morning?
Caretaker - Yes madam, Telma 40.
PPM 3 - Even then the BP is 160/110?
Caretaker - Yes madam.
PPM 3 - Let the patient take PCM (paracetamol) for headache.
Before sleeping in the night 10mg Flunarin.
Caretaker - After food?
PPM 3 - Yes.
PPM 3 - @PPM1 Sir patient took Telma 40mg in the morning
Complains of headache since afternoon
Afternoon she took PCM and headache subsided and now again it has relapsed. Patient has unilateral right sided headache. BP 160/110mmhg PR-80bpm.
PPM 1 - The BP rose because of the headache and headache may not be due to BP.
Caretaker - The patient has taken painkiller at 3pm. Can she take now at 7 pm?
PPM 3 - No
Caretaker - What does PCM mean?
PPM 3 - Paracetamol, like Dolo
Caretaker - After food?
PPM 3 - Yes.
Caretaker - BP at 20.40 132/69, PR -73
Dolo tablet is working good for the patient.
PPM 1 - 👍
We know that in acute headache the patient should be taking 6 hourly for a day and not stop after sos
10-01-2025
Caretaker - The BP reading at 9.30am is 160/103, PR 84
The patient took Cilnidipine, Olmesartan tablet.
PPM 3 - The patient should take Tab Telma 40mg.
PPM 1 - 👍
We should have added @PPM4 earlier so that he wouldn't have started this new drug the next day.
Caretaker - Madam the patient has already taken cilnidipine, can she take now Telma 40 again?
PPM 3 - No, please take from tomorrow the tab Telma 40.
PPM 1 - And then we can add amlodipine if telma 40 alone doesn't control it.
Both are available from government PHC and our rule of thumb can be to write whatever the patient need not have to buy but benefit from the taxpayer.
Why will he listen to you unless you and @PPM4 who wrote that drug come to a shared understanding and project it to the patient in a way he can relate to?
Caretaker - The BP reading after taking the tablet at 9.58 is 138/95, PR 81
PPM 3 - Please post the patient's BP readings for every 2 hours.
Caretaker - Okay madam.
At 11.35am the BP reading is 140/92, PR 88
PPM 3 - 👍
Caretaker - At 1.47 pm BP 145/89, PR 80
Caretaker - Today at 4.30pm BP is 156/108, PR 93
PPM 1 - What medication has she taken since morning?
PPM 3 - They took Cilnidipine Olmesartan.
PPM 1 - Today?
PPM 3 - Yes sir
PPM 1 - What about her previous telmisartan 40mg?
PPM 3 - Patient already took the medicine as advised by @PPM4 sir in the morning before our advise
PPM 1 - 👍
If necessary and if the subsequent BPs progress we can ask her to take the telmisartan too.
PPM 3 - Okay sir.
Caretaker - At 7.20pm BP 151/104, PR 88
PPM 1 - Can take the telmisartan 40 mg and from tomorrow we'll continue telmisartan twice daily and continue to share the BP here.
Caretaker - BP at 21.05 is 129/81, PR 99
Have not given BP tablet as it was in control.
PPM 1 - Ask him to check the BP again and again then.
The BP may have been in control only because of the medicine and will rise once the medicine effect subsides soon.
PA - 👍
PPM 1 - @SE hopefully we will be able to create a good graph for this patient similar to how you have done it with 63M.
SE - Okay sir 👍
Caretaker - Flunarin 10mg is working good at night time.
PPM 1 - 👍
Caretaker - Morning 10.19am BP 127/64, PR 87.
At 1.28pm BP 144/90, PR 80.
At 4.35pm BP 134/93 PR 102.
At 5.26pm BP 139/90
Caretaker - Should the patient take BP tablet now?
PPM 1 - Yes.
Caretaker - At 6.35pm BP is 142/103, PR 106.
PPM 1 - The patient has to take the BP tablet daily twicw. Morning and evening.
12-01-2025
Caretaker - BP at 11.14am is 145/87, PR 87
At 12.44pm 142/89, PR 86.
PPM 1 - Morning Telmisartan taken at what time? What dose? @PPM3
Caretaker - Telmisartan 40mg at 9.23am.
Caretaker - At 5.02pm BP 164/116, PR 124
PPM 1 - Share her hourly activities.
Caretaker - Ok
At 8.52pm BP is 132/95, PR 112.
13-01-2025
PPM 1 - Evening telmisartan taken at what time?
Caretaker - At 8.00 pm.
PPM 1 - @SE do we have enough data here to prepare an intervention graph like the one you did for the 63M patient? Also would @PA like to try to prepare it using an Al LLM?
SE - 👍
Caretaker - BP at 9.10am is 157/109, PR 105. The patient took the tablet at 9.10am.
PPM 1 - BP recording after 8:52 PM yesterday? 132/95
@PA you may notice why the BP is getting uncontrolled as the telmisartan 40 is unable to act till 9:00 AM the next day (so perhaps it's not even working for 12 hours)! @PPM2 is it text book teaching that it works for 24 hours and is hence recommended once daily? Are these PaJR records really going to challenge conventional textbook assumptions of BP control?
Caretaker - At 12.35pm BP 167/99, PR 110
PPM 1 - Yes, only till we are able to optimize the drug dosages and interval he needs to take this extra trouble for preparing an intervention graph.
SE - Sir atleast a week's data with proper medication name/timing and bp values documented will be helpful to plot a graph and identify any pattern.
Just like 63M have submitted the data with continuity.
Caretaker - At 1.24pm BP is 137/88, PR 100
PA - I explained clearly to him and asked to post hourly BP readings for 1 week.
Patient 's Daily Activities.
6 am Wake up
6.30 am -Tea
6-30-11 - Domestic work, like cleaning, washing clothes, cooking etc.
10am - Lunch
11am-5pm - Talk to neighbours, sleep.
6pm - Tea.
7pm - Cooking dinner.
9pm - Go to bed.
The patient's husband is a paralysis patient. Her elder son goes to work and the younger one is a student.
No comments:
Post a Comment